Chapter 16 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 16

Question 1

Type: MCSA

A nurse is providing information to a group of new mothers. The nurse would explain that newborns and young infants are more susceptible to infection because they have

1. High levels of maternal antibodies to diseases to which the mother has been exposed.

2. Passive transplacental immunity from maternal immunoglobulin G.

3. Immune systems that are not fully mature at birth.

4. Been exposed to microorganisms during the birth process.

Correct Answer: 3

Rationale 1: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns and young infants high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Rationale 2: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns and young infants high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Rationale 3: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns and young infants high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Rationale 4: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns and young infants high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 01. Explain why children are more vulnerable than adults to communicable diseases.

Question 2

Type: MCSA

A 3-year-old child is lying in a fetal position. The child has pale skin, glassy eyes, and a flat affect. The child is irritable and refuses food and fluids. The childs vital signs are temperature 40.1 degrees C (104.2 degrees F), pulse 120/min, respirations 28/min. The best, most comprehensive description of this childs condition is

1. Toxic.

2. Feverish.

3. Flushed.

4. Tired.

Correct Answer: 1

Rationale 1: The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis. The child has a high fever, and the child may be tired, but these words are not the best, most comprehensive description of the childs condition. The term flushed is incorrect because it indicates a reddish appearance to the skin. The child has pale skin, which would be a white appearance to the skin.

Rationale 2: The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis. The child has a high fever, and the child may be tired, but these words are not the best, most comprehensive description of the childs condition. The term flushed is incorrect because it indicates a reddish appearance to the skin. The child has pale skin, which would be a white appearance to the skin.

Rationale 3: The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis. The child has a high fever, and the child may be tired, but these words are not the best, most comprehensive description of the childs condition. The term flushed is incorrect because it indicates a reddish appearance to the skin. The child has pale skin, which would be a white appearance to the skin.

Rationale 4: The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis. The child has a high fever, and the child may be tired, but these words are not the best, most comprehensive description of the childs condition. The term flushed is incorrect because it indicates a reddish appearance to the skin. The child has pale skin, which would be a white appearance to the skin.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 05. Differentiate between common communicable diseases.

Question 3

Type: MCSA

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse also may give which of the following immunizations during the same well-child-care appointment?

1. Var (varicella).

2. TIV (influenza).

3. MMR (measles, mumps, rubella).

4. Haemophilus influenza type B (HIB).

Correct Answer: 4

Rationale 1: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 48 weeks apart.

Rationale 2: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 48 weeks apart.

Rationale 3: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 48 weeks apart.

Rationale 4: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 48 weeks apart.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Prepare a nursing care plan for children of all ages needing immunizations.

Question 4

Type: MCSA

A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. The nurses most appropriate response to this mother is to

1. Honor her request because she is the parent.

2. Explain that antibodies can fight many diseases.

3. Tell her that not immunizing her infant may protect pregnant women.

4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

Correct Answer: 4

Rationale 1: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mothers belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Rationale 2: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mothers belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Rationale 3: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mothers belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Rationale 4: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mothers belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Summarize the role vaccines play in reduction and elimination of communicable diseases.

Question 5

Type: MCSA

A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. The nurse recognizes that this child may have

1. Chicken pox (varicella).

2. German measles (rubella).

3. Roseola (exanthem subitum).

4. Fifth disease (erythema infectiosum).

Correct Answer: 4

Rationale 1: Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Rationale 2: Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Rationale 3: Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Rationale 4: Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 05. Differentiate between common communicable diseases.

Question 6

Type: MCSA

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which of the following needles, size and length, injection type, and injection site?

1. 25-gauge, -inch needle; IM (intramuscular); anterolateral thigh.

2. 22-gauge, -inch needle; IM (intramuscular); ventrogluteal.

3. 25-gauge, -inch needle; ID (intradermal); deltoid.

4. 25-gauge, -inch needle; SQ (subcutaneous); anterolateral thigh.

Correct Answer: 1

Rationale 1: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, to -inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Rationale 2: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, to -inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Rationale 3: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, to -inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Rationale 4: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, to -inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 04. Prepare a nursing care plan for children of all ages needing immunizations.

Question 7

Type: MCSA

Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. To reach this goal, the school nurse can teach families that:

1. A minor illness with a low-grade fever is a contraindication to receiving an immunization according to Healthy People 2020.

2. Vaccines should be given one at a time for optimum active immunity in the prevention of illness and disease.

3. Premature infants and low-birth-weight infants should receive half doses of vaccines for protection from communicable diseases.

4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.

Correct Answer: 4

Rationale 1: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Rationale 2: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Rationale 3: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Rationale 4: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Summarize the role vaccines play in reduction and elimination of communicable diseases.

Question 8

Type: MCSA

A 2-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth 10 days for otitis media. To guard against antibiotic resistance, the nurse instructs the parent to

1. Administer a loading dose for the first dose.

2. Measure the prescribed dose in a household teaspoon.

3. Give the antibiotic for the full 10 days.

4. Stop the antibiotic if the child is afebrile.

Correct Answer: 3

Rationale 1: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Rationale 2: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Rationale 3: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Rationale 4: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Describe the process of infection and modes of transmission.

Question 9

Type: MCSA

The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. The nurse who correctly understood the presentation is the one who identifies her action to be

1. Separating clients according to age and illness to prevent the spread of disease.

2. Disposing of blood-contaminated needles in the lead-lined container.

3. Notifying the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room.

4. Initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).

Correct Answer: 3

Rationale 1: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Rationale 2: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Rationale 3: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Rationale 4: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Describe the medical and nursing management of common communicable diseases.

Question 10

Type: MCMA

The school nurse is trying to prevent the spread of a flu virus through the school. Infection-control strategies that may be employed include

Standard Text: Select all that apply.

1. Teaching parents safe food preparation and storage.

2. Withholding immunizations for children with compromised immune systems.

3. Sanitizing toys, telephones, and door knobs to kill pathogens.

4. Separating children with infections from children who are well.

5. Teaching children to wash their hands after using the bathroom.

Correct Answer: 3,4,5

Rationale 1: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 2: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 3: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 4: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Rationale 5: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Describe the process of infection and modes of transmission.

Question 11

Type: MCMA

The nurse is teaching a prenatal class about infant care. The nurse emphasizes that parents should call their health-care provider immediately if their infant

Standard Text: Select all that apply.

1. Is 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0 degrees C (100.4 degrees F).

2. Is under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F).

3. Is difficult to awaken and has a pulsing fontanel.

4. Has purple spots on the skin and is lethargic.

5. Has a stiff neck and has been irritable for three days.

Correct Answer: 2,3,4,5

Rationale 1: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 2: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 3: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 4: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Rationale 5: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Differentiate between common communicable diseases.

Question 12

Type: MCSA

The hospital admitting nurse is taking a history of a childs illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media when they reported that they

1. Used aspirin every four hours to reduce the fever.

2. Alternated acetaminophen with ibuprofen every two hours.

3. Put the child in a tub of cold water to reduce the fever.

4. Offered generous amounts of fluids frequently.

Correct Answer: 4

Rationale 1: The bodys need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the childs weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Rationale 2: The bodys need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the childs weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Rationale 3: The bodys need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the childs weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Rationale 4: The bodys need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the childs weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 06. Describe the medical and nursing management of common communicable diseases.

Question 13

Type: MCSA

A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the 4-month-old was exposed to a brother who has the flu. In this case the nurse will

1. Withhold the vaccinations.

2. Give the vaccinations as scheduled.

3. Withhold the DTaP vaccination but give the others as scheduled.

4. Give the infant the flu vaccination but withhold the others.

Correct Answer: 2

Rationale 1: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Rationale 2: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Rationale 3: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Rationale 4: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 04. Prepare a nursing care plan for children of all ages needing immunizations.

Question 14

Type: MCSA

A parent brings her 6-year-old child to the clinic because the child has a temperature of 100.2F. The child remains active without other symptoms. The nurse may appropriately tell the parent to:

1. Take the childs temperature every 2 hours and call the clinic if it reaches 102F or above.

2. Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection.

3. Keep the child warm, because shivering often occurs with fever.

4. Alternate acetaminophen and ibuprofen to help keep the fever down and keep the child comfortable.

Correct Answer: 2

Rationale 1: Fever is the bodys response to an infection, and is not a disease. Allowing the bodys natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the childs temperature more than every 46 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Rationale 2: Fever is the bodys response to an infection, and is not a disease. Allowing the bodys natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the childs temperature more than every 46 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Rationale 3: Fever is the bodys response to an infection, and is not a disease. Allowing the bodys natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the childs temperature more than every 46 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Rationale 4: Fever is the bodys response to an infection, and is not a disease. Allowing the bodys natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the childs temperature more than every 46 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Describe the process of infection and modes of transmission.

Question 15

Type: MCMA

A child is admitted with a diagnosis of early localized Lyme disease. On initial assessment, the nurse would expect to see what signs/symptoms?

Standard Text: Select all that apply.

1. Erythema 515 cm in diameter.

2. Hyperactivity.

3. Cranial nerve palsies.

4. Fever.

5. Headache.

Correct Answer: 1,4,5

Rationale 1: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 2: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 3: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 4: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Rationale 5: Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Differentiate between common communicable diseases.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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